How leading hospitals in the US and Europe achieved excellence in service quality - and sustained it Dr Glenn Robert, UCL Professor Paul Bate, UCL Dr Peter

How leading hospitals in the US and Europe

achieved excellence in service quality - and

sustained itDr Glenn Robert, UCL

Professor Paul Bate, UCLDr Peter Mendel, RAND Corporation

Funding: The Nuffield Trust, London & RAND Corporation, US

© Paul Bate & Glenn Robert, University College London 2005. All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright owner

Presentation to 6th International Conference on the Scientific Basis of Health Services, 2005, Montreal

2

Objective

To re-trace the ‘quality journey’ of 8 high performing health care

organizations in order to explore the processes that enabled them to

successfully implement, spread and sustain quality improvement

initiatives

3

Background

The quality lottery: striking variation between health care organizations

in how successful they are in implementing and sustaining Q &

SI

4

One large study of American health care

qualitySource: McGlynn et al (2003) NEJM, 348, pp. 2635-2645

439 indicators of clinical quality of careAcross 30 acute and chronic conditions

Participants (N=6712) had received 54.9% of scientifically indicated care

Conclusion:The ‘defect rate’ in the technical quality of

American health care is approximately 45%

It is probably the same in the UK!

5

Background

• HSR getting better and better at measuring health outcomes and quality

• Variation between (Jarman) and within (Adler) health care organizations

• Strong on the ‘what’ but weaker on the ‘why’ and ‘how’

• Most HSR related to quality issues does not seek to explain the human and organisational causes of variation

6

Background

• Move from describing to explaining• Processes and dynamics of

improvement rather than list of ‘key success factors’

• Ethnographic case studies of organizations with a history and reputation for sustained quality improvement

7

Organizational sample• United States

– Albany Medical Center (AIDS Treatment Center)– Cedars-Sinai (Emergency Department)– Luther Midelfort Mayo Health System (Critical Care

Unit)– San Diego Children’s Hosp. (Allergy & Immunology)– SSM St. Joseph’s Health Center (Intensive Care Unit)

• Netherlands– Reinier de Graaf Groep (Flow Varicies -- Vascular

Surgery)

• United Kingdom– Peterborough Hospitals (Radiology Services)– Royal Devon and Exeter (Orthopaedic Centre)

8

ALBANY

PETERBOROUGH

EXETER

DELFT

ST. LOUIS

SAN DIEGO

EAU CLAIRELOS ANGELES

9

Study design• 15 days fieldwork in each site • Semi-structured interviews: macro-

and micro-system• Direct observation and documentary

evidence• Draft narrative fed back to key

informants• Analysed shared narratives and

identified ‘challenges’, ‘elements’ and ‘processes’ that combine to explain improvement in health care

10

The generic challengesDespite huge variety similar sets of challenges:

1. Educational (a learning process to support continual improvement)

2. Political (addressing and dealing with the politics of change)

3. Cultural (giving ‘quality’ a shared, collective meaning, value and significance)

4. Emotional (engaging and mobilising people)5. Structural (organising, planning and co-

ordinating the improvement effort)6. Physical and technical (supportive

technologies and infrastructure)

11

Solutions to meet these challenges (elements)

1. Educational1.1 A quiet, reflective form of leadership1.2 Knowledge of ‘hard’ quality improvement methods

and techniques…

2. Political2.2 An agreed ‘compact’ for Q & SI between key interests2.4 A dispersed, devolved/decentralised authority system…

3. Cultural3.1 A philosophy and mission that highlights top quality

patient care3.7 An organisation whose image and identity are

inextricably bound up with the concept of ‘excellence in quality’ …

12

4. Emotional4.2 Building communities of practice and wider social

commitment to Q & SI4.6 Emotional involvement in the organisation

improvement effort…

5. Structural5.1 An explicit and formally signed off strategy for Q & SI5.10 Specialist interlocutor/connector roles with

regard to quality: ‘boundary spanners’ (linking resources, people and ideas)

…

6. Physical & technical6.1 A leadership that is aware of the material and

symbolic/aesthetic importance of buildings and architecture, and incorporate this into its concept of service design

6.2 Whether it is free-standing and has control over its own buildings and space, data and technical systems

…

13

Educational

Physical & Technological

Structural

Political

Cultural

Emotional

Task-centred leadershipQuality strategy & planWhole-systems designDevolved authorityMulti-level leadershipQuality leadership positionsQI governance structureQuality department/groupQI training programsCommunities of practiceData & monitoring systemsResults-oriented planningEnabling Admin roleBoundary spanner rolesOrganizational ‘slack’

Pedagogical leadershipOrganizational change knowledgeQI techniques knowledgeKnowledge harvestingExperimentation & pilotingEvidence-based learningExperience-based learning

Values/symbolic leadershipCulture of excellencePatient-centered ethicCulture of mindfulnessGroup/collaborative cultureScientific cultureCulture of learningFormality-savvy cultureCulture of empowermentCosmopolitan cultureLong term perspectiveOrganizational identityRecruitmentAcculturation

Inspirational leadershipClinical & other change championsCollective momentumProfessional & social affiliationsQuality as a mission/callingEmotional commitmentImprovement campaigns

Inner Context

Outer Context

OrganizationSize

OrganizationStructure

OrganizationPerformance

Market & ResourceEnvironmentsProfessional &

Social Movements

Regulatory Environments

TechnologicalEnvironments

Politically-credible leadershipClinical engagementPeer-to-peer relationshipsClinical-Managerial partneringEmpowering staffEmpowering patientsExternal partnering

Technology/design leadershipFunctional design of built envAesthetic design of built envInfo technology designMedical technology designLocating of built env & tech

14

Educational


Structural

Political

Cultural

Emotional





Inner Context

Outer Context

OrganizationSize




Social Movements





15

Educational


Structural

Political

Cultural

Emotional





Inner Context

Outer Context

OrganizationSize




Social Movements





?

16

RESULTS

So what processes enabled these health care

organizations to successfully implement,

spread and sustain Q & SI initiatives?

17

Cedars-Sinai, Los Angeles

• 875 beds• 6,600 staff and 1,700

affiliated physicians• Primary service area

consists of 2.3 million people ($70m p.a on community outreach)• Major teaching

hospital (UCLA)

A flavour .. two case studies

Peterborough• 670 beds (2 sites)

• 2,300 wte staff• Acute medical services

to 280,000 in east of England

• Income of £89.1m in 2001/02

• 3 star Trust 2001/02 and 2002/03

18

Process mapping method – Step One

Systematically coded the validated case narratives for mentions of processes between elements

19

An example

In this spirit, the hospital decided to hire this physician to lend clinical background and credibility to the quality effort [2.1 to 2.2]:

“So he… went around looking at evidence based stuff, and began to bring to the institution a whole discipline [3.8 to 5.15] around analyzing process, flow diagrams, cradle diagrams, privatization approaches,… and we began to infuse the organization with that approach. We linked up then with the national demonstration project later [1.4 to 3.10] becoming the Institute for Healthcare Improvement, [he] became faculty in the IHI, as you probably know, and kept us connected with a network of people who had a growing similar interest around these kinds of things” [5.10 to 1.4].

20

Process mapping method – Step Two

Employed social network analysis techniques to examine and visualize the patterns of

relations among the organizational processes for each case study

21

Cedars-Sinai Sub-Process Mapping

EducationalPoliticalCulturalEmotionalStructuralPhysical/TechnicalInner ContextOuter Context

IC1.1

C3.1

C3.10

C3.11

C3.12

C3.13

C3.14

C3.2

C3.3

C3.5

C3.6 C3.7

C3.8

ED1.1

ED1.2ED1.3

ED1.4ED1.5

ED1.6

ED1.7

EM4.1

EM4.2

EM4.3

EM4.4

EM4.5

EM4.6

IC1.2

IC1.3

OC1.4

OC1.5

OC1.6

OC1.7

P2.1

P2.2 P2.3

P2.4P2.5

P2.7PT6.1

PT6.2

PT6.3

PT6.5

PT6.6

S5.1

S5.10

S5.11

S5.12

S5.13

S5.14

S5.15

S5.2

S5.3

S5.4

S5.5

S5.6

S5.7

S5.8

S5.9

Note: Dotted line indicates negative relationship.

22

Cedars-Sinai Sub-Process Mapping


OrgSize

CExcell

C Cosmop

LTermC

OrgIdentity

RecruitRetain

Socializ

ValuesLship

PatientCentred

GroupC

C Science LearnC

C Formal

PedagLship

OrgChngTraining

QITraining

Experm

Evid-basedLearning

Exp-basedLearning

InspLship

ClinChampions

CollMoment

Profl-SocialAffiliations

QMission

EmotInvlv

OrgStruc

OrgPerf

RegulatoryEnvironment

Mrkt/ResourceEnvironment

SocialMvmnts

AvailTechn

CredLship

ClinEng Peer-to-Peer

Clin-Mgt Prtnr

StaffEmpw

ExtPrtnrPT6.1

PhysAesthetics

Techn/DesignLship

ICTSupp

ClinTechnSupp

QStrategy

BndrySpans

Comm-ofPractice

PlanProcess

QGovern

QSlackRes

DataSys

TaskLship

WholeSysDes

DecAuth

QLdrs

DistrLdrs

QIdept

QTrainingPrograms

EnablingAdmin

Note: Dotted line indicates negative relationship.

KHarvest

23

Cedars-Sinai Process Mapping

Structural 80 30% 29% 41%Communities-of-Practice, Quality governance systems, Distributed leadership, Data and monitoring systems, Boundary-spanner roles

Cultural 69 23% 39% 38% Group culture, Values/symbolic leadership, Culture of learning

Educational 41 5% 51% 44% Political 30 13% 50% 37% Clinical engagement

Emotional 13 15% 62% 23% Physical & Technical 11 0% 27% 73% Outer Context 4 25% 75% 0% Inner Context 3 0% 33% 67%

Most Central Sub-ProcessesOUT-ties (%)

ProcessTotal Sub-

Process Ties (#)

W/in Process

(%)IN-ties

(%)

24

Peterborough Sub-Process Mapping


IC1.1

PT6.6

S5.10

S5.11

S5.13S5.14

S5.15

S5.2

S5.3

S5.4

S5.5

S5.6

S5.7

S5.8

S5.9

ED1.1

ED1.2

ED1.3

ED1.4

ED1.5

ED1.6

ED1.7

IC1.2

IC1.3

PT6.5

OC1.4

OC1.5

OC1.6

C3.1

C3.11

C3.12

C3.13

C3.2

C3.5

C3.6

C3.7

C3.9

EM4.1

W4.3

EM4.6

P2.1

P2.2

P2.3

P2.4

P2.5

P2.7

25


OrgSize

ClinTechnSupp

BndrySpans

Comm-of-Practice

QGovernQSlackRes

DataSys

TaskLship

WholeSysDes

DecAuth

QLdrs

DistrLdrs

QIdept

QTrainingPrograms

EnablingAdmin

PedagLship

OrgChngTraining

QITraining

KHarvest

Experm

Evid-basedLearning

Exp-basedLearning

OrgStruc

OrgPerf

ICTSupp

RegulatoryEnvironment

Mrkt/ResourceEnvironment

SocialMvmnts

CExcell

LTermC

OrgIdentity

RecruitRetain

ValuesLship

GroupC

ScienceC

LearnC

EmpwC

InspLship

Coll Momen

t

EmotInvlv

CredLship

ClinEng

Peer-toPeer

Clin-Mgt Prtnr

StaffEmpw

ExtPrtnr

Peterborough Sub-Process Mapping

26

Peterborough Process Mapping

Structural 52 25% 10% 65% QI facilitating team, Enabling administrative role Cultural 49 14% 71% 14% Culture of empowerment, Group culture Political 43 7% 56% 37% Empowering staff, Clinical engagement Educational 26 8% 50% 42% Experimentation & pilots Outer Context 7 0% 29% 71% Inner Context 6 0% 0% 100% Physical & Technical 6 0% 33% 67% Emotional 5 20% 60% 20%

OUT-ties (%)

Most Central Sub-Processes ProcessTotal Sub-

Process Ties (#)

W/in Process

(%)IN-ties

(%)

27

Comparative Process Mappings

Cedars-SinaiPeterborough

28

.. and the emotional“People here aren’t just motivated. This isn’t

their job, it’s a mission, it’s their life, it’s the cause they’re committed to. For them, it’s

personal.” (Director HIV AIDS Programme, Albany Medical Centre, New York)

“Perfect care is something we never reach, but like the North Star, it serves as a

beacon to guide us … Every day Children’s should strive to be even better than before.

Our physicians, our nurses, and our staff seek to attain it; our families deserve it.”

(Foreword of the Children’s Agenda, Children’s Hospital and Health Centre’s strategic and business plan, June 2001)

29

Conclusions• The generic but variable thesis: ‘many

paths up the mountain’• Failures and ‘bumps in the road’• Multi-level, multi-dimensional process

based model of service improvement• Context and physical/technology factors

important in realising quality but cultural and structural response of organizations largely determine whether QI is sustained

• Yes, human and organisational factors are important – and need to understand ‘how’ and ‘why’

30

Jeopardising change

Lack of a … Can lead to…

Learning process Amnesia or frustration

Political process Inertia

Cultural process Evaporation

Mobilisation Energy-sink

Planning & co-ordination Fragmentation

Physical infrastructure & technical systems

Exhaustion

31

For comments and further information:

[email protected]

Organizing for Quality: Journeys of Improvement at Leading

Healthcare Organizations in the US & UK

James L. Zazzali, Ph.D., M.P.H., RAND Corporation

Glenn Robert, Ph.D., UCL Medical School

Peter Mendel, Ph.D., RAND Corporation

Paul Bate, Ph.D., UCL Medical School

Funding Sources:

Nuffield Trust, London

RAND Corporation Health Unit, Santa Monica

Copyright, all rights reserved, 2005

33

Research Objectives

• To present cross-site and cross-national findings regarding the ability of healthcare organizations to sustain QI programs and processes

• To identify best practices in change management related to the introduction and implementation of QI

• To approach this with a decidedly organizational perspective

34

Study Design

• Mixed methods with a multilevel approach• Interviews with over 100 senior leaders at 11

Health care systems in 3 countries (results today only for US & UK)

• Site visits to one “high performing” department within each of the 11 health systems to observe and interview staff

• Interview data used to construct survey items• Survey of staff in the “high performing”

departments

35

Organizational Sample• United States

– Albany Medical Center (AIDS Treatment Center)– Cedars-Sinai (Emergency Department)– Geisinger Health System (Rheumatology)– Luther Midelfort Mayo Health System (Critical Care Unit)– San Diego Children’s Hosp. (Allergy & Immunology)– SSM St. Joseph’s Health Center (Intensive Care Unit)

• Netherlands– Reinier de Graaf Groep (Flow Varicies -- Vascular Surgery)

• United Kingdom– Kettering General Hospital (Accident & Emergency

Services)– Kings College (Breast Unit)– Peterborough Hospitals (Radiology Services)– Royal Devon and Exeter (Orthopaedic Centre)

36

Survey of “High Performing” Departments

• Survey measured:– The degree to which 9 key factors related to

sustaining QI efforts were met in the department– Perceptions of importance of these factors for 5 of

the 9 areas– The organizational culture of the department– The respondents’ level of QI training and QI team

experience– Respondents’ socio-demographic characteristics

• Survey sample– 477 respondents across 10 sites in the US & UK– 48% response rate with two mailings

37

Nine Factors Related to Sustaining QI

• Organizational slack for quality improvement• Quality resource infrastructure• Availability and use of data• Culture of sharing and learning• Distribution of responsibility• Organizational identity• Senior leaders creating a vision, scripting &

motivating• Communication and discourse• Systems perspective/thinking

38


• A. Organizational slack for quality improvement– 1) Our unit provides staff with time and other resources to

work on implementing new ways of improving how we do things here.

– 2) I have opportunities to visit or interact with people in other units or outside this organization to bring back new ideas which might improve how we do things here.

• B. Quality resource infrastructure– 3) Our unit has access to people who can provide training,

advice and support in quality improvement.

• C. Availability and use of data– 4) Our unit has easy access to data that is useful for

understanding the processes and outcomes of our work.– 5) Our unit routinely makes changes based on

measurement of the processes and outcomes of our work.

39


• D. Culture of sharing and learning– 6) People in our unit like to share their ideas and

expertise with one another.

• E. Distribution of responsibility– 7) My efforts can play an important role in the success

of quality improvement activities in this unit.– 8) Quality improvement activities can produce

significantly better patient care and outcomes in our unit.

• F. Organizational identity– 9) This organization has a mission or purpose that I

strongly identify with.– 10) This organization has a particular history that I am

proud of.

40


• G. Senior leaders creating a vision, scripting & motivating– 11) Senior management within this organization know how to

inspire and motivate staff across areas to work toward common goals.

– 12) Senior management within this organization make improving the quality of patient care a priority.

• H. Communication and discourse– 13) People in our unit feel they can freely express their views and

have their opinions listened to.– 14) There is good communication between our unit and others in

the organization on important issues of delivering patient care.

• I. Systems perspective/systems thinking – 15) People in our unit really understand how patients move across

departments within this organization.– 16) There is strong inter-departmental coordination within this

organization.

41

Challenges in Sustaining QI

4.0

4.1

4.4

4.4

4.5

3.8

3.9

4.2

4.2

4.0

1.0 2.0 3.0 4.0 5.0 6.0

Sr. mgmt. knows how to inspire & motivate staff acrossareas to work toward common goals.

Opportunities to visit or interact with people in otherunits or outside this organization to bring back new

ideas

People in our unit like to share their ideas and expertise

There is good comm. between our unit and others onimportant issues of delivering patient care

There is strong inter-departmental coordination

US UK

*

*

*

*

* denotes p<.05

42

Advances in Sustaining QI

5.3

5.2

5.2

5.1

5.0

4.7

5.0

5.0

5.0

4.8

1.0 2.0 3.0 4.0 5.0 6.0

This organization has a mission or purpose that Istrongly identify with.

QI activities can produce significantly better patientcare and outcomes

My efforts can play an important role in the successof QI activities

This organization has a particular history that I amproud of.

People in our unit feel they can freely express theirviews and have their opinions listened to

US UK

*

*

*

*

* denotes p<.05

43

Importance of Factors Related to QI Sustainability

5.7

5.6

5.5

5.4

5.4

5.7

5.5

5.1

5.3

5.4

1.0 2.0 3.0 4.0 5.0 6.0

Training and time forimproving quality of

patient care and service

Senior managementmakes improving the

quality of patient care apriority

This organization has amission or purpose that I

strongly identify with

People in departmentunderstand how patientsmove across departments

in this organization

Access to professionalstaff for training, support

and advice on qualityimprovement

US UK

*

*

*

* denotes p<.05

44

QI Training & Participation

36

51

11

15

0 10 20 30 40 50 60

Have you been trained in formal quality improvement principlesand techniques (e.g., principles espoused by Deming or Juran, Six

Sigma, Rapid Cycle, Plan-Do-Study-Act, or other qualityimprovement techniques like Process Mapping, Root Cause

Analysis, etc.

Have you ever served on a quality improvement team in thisorganization (i.e., a team specifically formed to analyze and

improve the quality of care or service)?

US (% Yes) UK (% Yes)

*

*

* denotes p<.05

45

QI Training

23

33

46

36

7

0

19

11

0 5 10 15 20 25 30 35 40 45 50

Non-clinical

Physicians

Nurses

Total

US % Yes UK % Yes

46

QI Team Participation

38

56

57

51

7

17

22

15

0 10 20 30 40 50 60

Non-clinical

Physicians

Nurses

Total

US % Yes UK % Yes

47

Differences inOrganizational Culture

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0Group Culture (teamwork & affiliation)

Developmental Culture (risktaking/entrepreneurial)

Hierarchical Culture (bureaucracy)

Rational Culture (task oriented)

US UK

48

Conclusions

• These organizations face similar challenges & successes for QI implementation and sustainability

• QI training and participation are more diffuse in the US

• The organizational cultures are different for the US & UK sites

49

Next Steps

• Multivariate (and multilevel) models of individuals’ perceptions of key factors related to sustaining QI and their importance, predicted by organizational culture and QI training and participation

• Book presenting case studies and synthesizing an organizational model of factors related to QI sustainability

50

Components to a process model of improvement

?? processes

63 elements

6 generic challenges

- Inner context- Outer context

Receptive context

Documents

How leading hospitals in the US and Europe achieved excellence in service quality - and sustained it Dr Glenn Robert, UCL Professor Paul Bate, UCL Dr Peter